Mayo Clinic's approach

Your Mayo Clinic care team

Mayo Clinic doctors trained in diagnosing heart and blood vessel conditions, called cardiovascular medicine, and Mayo Clinic surgeons trained in surgery of the heart and blood vessels, called cardiovascular surgery, have expertise evaluating and treating all aortic conditions. They work as a team to deliver coordinated care.

Mayo Clinic surgeons have wide experience with complex procedures such as aortic surgery, including aortic root replacement and valve-sparing aortic root repair. Aortic specialists at Mayo Clinic evaluate people with aneurysms. This evaluation includes a thorough personal and family history and a detailed assessment to find the cause of an aneurysm. Your Mayo Clinic health care team works together to determine the best treatment and timing of surgery for you.

Consultation with genetic specialists and genetic testing is often recommended for those with a family history of aneurysms. It's also recommended for those who are younger than 70 when an aortic aneurysm is diagnosed.

Detailed diagnosis

Mayo Clinic doctors use detailed imaging tests, such as transesophageal echocardiogram, CT coronary angiogram and magnetic resonance angiogram to diagnose aortic aneurysms. These imaging tests can look for tears in the inner layer of the aortic wall, called aortic dissection. They also can help determine the most appropriate treatment for your condition.

Advanced treatment

Mayo Clinic offers several types of aortic root surgery, including aortic valve and root replacement and valve-sparing aortic root repair. In valve-sparing surgery the aortic valve remains in place.

Valve-sparing aortic root replacement: What patients need to know

Alberto Pochettino, M.D., Cardiovascular Surgery, Mayo Clinic: My name is Alberto Pochettino. I'm a cardiovascular surgeon at Mayo Clinic in Rochester, Minnesota. I have a special interest in aortic surgery and today I will discuss the operation known as valve-sparing aortic root replacement. The aortic root is the beginning of the aorta. It is located at the transition between the main pumping chamber of the heart and the remainder of the aorta. It contains the aortic valve and the origin of the coronary arteries. Replacement of the aortic root is indicated in the presence of an aortic aneurysm. An aneurysm is an abnormal enlargement of a blood vessel. The maximum diameter of the aneurysm is used to assess the risk of rupture or dissection. At the level of the aortic root, 5.5 centimeter in maximum diameter is felt to be the size at which replacement surgery should be performed in most patients. Conditions in which the aortic wall is intrinsically weaker mandate intervention at a lower size. Most of these conditions are due to genetic abnormality of the aortic wall. The classic abnormality is Marfan syndrome but other rare abnormalities have been defined such as Ehlers-Danlos syndrome, Loeys-Dietz syndrome and a few others. However, by far the most common genetic aortic abnormality affecting the aortic root is bicuspid aortic valve disease. In all of these patients with higher risk condition, the trigger for surgical intervention should be lowered to 5 centimeter for many bicuspid aortic valve and 4.5 centimeter for most Marfan and other more severe genetic abnormalities.

Historically, replacement of the aortic root require replacement of the aortic valve contained within it, even when the valve may not have been significantly diseased. In younger individuals, a mechanical aortic valve would have been recommended because of its durability but it requires life-long anticoagulation with blood thinners such as coumadin. The alternative tertiary valve would not require coumadin but has limited lifespan necessitating reoperation. The reluctance to replace the aortic root when found within the normal aortic valve prompted development in 1980s of techniques to spare the native valve. The first attempt came to be known as "remodeling" followed by the reimplantation technique first reported by Tirone David. The reimplantation technique, over subsequent years, has proved to be the most durable. The surgical principle is to replace the entire aortic root from the ventricular annular junction to the so-called sinutubular junction with a Dacron graft tube. Within this tube, the three-dimensional aortic valve is reimplanted, thus the name. Over the subsequent years, the aortic root reimplantation, sometimes known as David operation, has been shown to be safe and effective in a specialized center performed by dedicated aortic surgeons. While long-term results have been very positive, in some patients, the native aortic valve may still deteriorate requiring long-term monitoring and, in some individuals, eventual replacement. Over the years, factors have been identified that impact the successful outcome of the procedure. For example, the larger the aneurysm, the more distortion the aortic valve leaflet will suffer leading to worse aortic valve insufficiency. The more long-standing aortic insufficiency, the more fibrosis and abnormality occur in the leaflets leading to a lower success in sparing the valve and a lower long-term durability of the spared valve. This has led to earlier intervention in select patients to allow for a durable valve function within the replaced root.

Despite this general tendency of earlier surgery, my practice has continued to use maximum aortic diameter combined with genetic risk factors to justify root replacement. Early in the development of valve-sparing root replacement, bicuspid aortic valves were not considered eligible due to the intrinsic abnormality of those valves. More recently good results have been achieved in the treatment of root aneurysm where bicuspid aortic valves are well functioning. While long-term outcomes in this set of patients may be less optimal than in the trileaflet aortic valve, a spared bicuspid valve is likely to be quite durable as well. Unfortunately a significant fraction of bicuspid valves in patients with root aneurysm are not normal and still require valve replacement.

In summary, the aortic root replacement should be dictated by the size of the aortic root aneurysm as well as the genetic risk factors. When the aortic valve leaflets are of good quality and can be spared, they should be. However, if the leaflets have significant abnormalities and the repair is not likely to be durable, the valve should be replaced with an appropriate prosthesis to meet the needs of the individual patient. Clinical judgment should be used both when deciding when to operate such that premature intervention is avoided as well as at surgery to maximize the benefit to the patient even if that may occasionally mean replacement of the aortic valve.

Expertise and rankings

Mayo Clinic cardiologists and cardiovascular surgeons have expertise and experience evaluating and treating all aortic conditions. Mayo cardiac surgeons perform more than 230 aortic root surgeries each year.

Nationally recognized expertise

Mayo Clinic campuses are nationally recognized for expertise in cardiology and cardiovascular surgery:

  • Mayo Clinic in Rochester, Minn., Mayo Clinic in Phoenix/Scottsdale, Ariz., and Mayo Clinic in Jacksonville, Fla., are ranked among the Best Hospitals for heart and heart surgery by U.S. News & World Report.
  • Mayo Clinic Children's Center in Rochester is ranked the No. 1 hospital in Minnesota, and the five-state region of Iowa, Minnesota, North Dakota, South Dakota and Wisconsin, according to U.S. News & World Report's 2023–2024 "Best Children's Hospitals" rankings.

Learn more about Mayo Clinic's cardiovascular medicine and cardiovascular surgery departments' expertise and rankings.

Locations, travel and lodging

Mayo Clinic has major campuses in Phoenix and Scottsdale, Arizona; Jacksonville, Florida; and Rochester, Minnesota. The Mayo Clinic Health System has dozens of locations in several states.

For more information on visiting Mayo Clinic, choose your location below:

Costs and insurance

Mayo Clinic works with hundreds of insurance companies and is an in-network provider for millions of people.

In most cases, Mayo Clinic doesn't require a physician referral. Some insurers require referrals or may have additional requirements for certain medical care. All appointments are prioritized on the basis of medical need.

Learn more about appointments at Mayo Clinic.

Please contact your insurance company to verify medical coverage and to obtain any needed authorization prior to your visit. Often, your insurer's customer service number is printed on the back of your insurance card.

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Mayo Clinic in Arizona, Florida and Minnesota

Mayo Clinic Health System

Jan. 18, 2023
  1. Selke FW, et al., eds. Aortic valve-sparing operations. In: Atlas of Cardiac Surgical Techniques. 2nd ed. Elsevier; 2019. Accessed Oct. 7, 2022.
  2. Burke CR. Overview of open surgical repair of the thoracic aorta. Accessed Oct. 7, 2022.
  3. Irimie V, et al. Long-term outcomes after valve-sparing anatomical aortic root construction in acute dissection involving the root. The Journal of Thoracic and Cardiovascular Surgery. 2019; doi:10.1016/j.jtcvs.2019.04.036.
  4. Ami T. Allscripts EPSi. Mayo Clinic. Oct. 4, 2022.
  5. Choudhary S, et al. Aortic root surgery in Marfan syndrome. Indian Journal of Thoracic and Cardiovascular Surgery. 2019; doi:10.1007/s12055-018-0761-9.
  6. Elghannam M, et al. Minimally invasive aortic root surgery: Midterm results in a 2-year follow-up. Journal of Cardiac Surgery. 2020; doi:10.1111/jocs.14628.
  7. Patlolla SH, et al. Outcomes and risk factors of late failure of valve-sparing aortic root replacement. Journal of Thoracic and Cardiovascular Surgery. 2020; doi:10.1016/j.jtcvs.2020.09.070.